Case ReportA case of necrotizing fasciitis following intra-articular injections – Iatrogenic or spontaneous?
Graphical abstract
Introduction
Necrotizing fasciitis is one of the severe soft-tissue infectious diseases with high morbidity [1]. It is classified into 4 types based on its pathogens: type 1: mixed flora of aerobes and anaerobes, type 2: monomicrobial mainly due to Gram-positive coccus like group A Streptococcus or Staphylococcus aureus, type 3: monomicrobial due to Gram-negative microorganism such as Vibrio vulnificus, and type 4: fungal [2]. Group A Streptococci secret lots of virulent factors, some of which contribute to the pathogenesis of necrotizing fasciitis and subsequent streptococcal toxic shock syndrome (STSS) [3]. A significant increase in the severe group A streptococcal infection has been reported since the late 1980s with a fatality of 30 % [4], and both accidental skin injuries and iatrogenic ones due to injection and surgery seem one of the major causal factors [4], [5], [6], [7], [8], [9].
Intra-articular injection (IA injection) of hyaluronic acid (HA) is widely employed for the supportive treatment of osteoarthritis [10]. Especially, IA injection of HA has significantly lower odds of infections and infestations in comparison with placebo. However, there is only one report case of necrotizing fasciitis following IA injection of HA in a patient under chemotherapy after the resection of breast cancer [11]. Here, we report a case of necrotizing fasciitis after intra-articular injection of hyaluronic acid.
Section snippets
Case history
At 8:30 AM of a certain day, a previously healthy 73-year-old female consulted an orthopedic clinic due to arthralgia in the left shoulder and the left knee. At the clinic, she was intra-articularly injected hyaluronic acid on the left shoulder and knee, based on the diagnosis of shoulder periarthritis and knee osteoarthritis. According to her husband, she continued complaining of pain in the left shoulder and knee. She was last seen sleeping near the sofa of the living room at about 10:00 PM.
Discussion
In this case, typical necrotizing fasciitis was found at the left upper and lower extremity both macroscopically and histopathologically. Moreover, bacteriological investigation detected group A Streptococcus on the blood and muscle tissues. Based on these findings, the cause of her death was diagnosed as streptococcal toxic shock syndrome (STSS) with a concomitant of necrotizing fasciitis.
In 1987, the first two cases of STSS, which gained its name after the toxic shock syndrome caused by
Ethical approval
This article does not contain any studies with animals performed by any of the authors.
Informed consent
The article does not include participants from whom informed consent was required.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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